FAMILY COUNSELING FORM

Family Information
Are there any close family members not living in the home?
Adopted?
Behavior Concerns
Is there a history of, or current concern with any of the following? If so, how long have these been problems?
Describe relationship between your child and the following people:
Treatment (Current and Previous)
Individual Therapy
Individual Therapy
Individual Therapy
Family Therapy
Family Therapy
Intensive Outpatient Programs (IOP)
Partial Hospitalization Program (PHP)
Impatient
Impatient
Family History
Is there a family history of mental illness in your family?
Is there a family history of substance abuse in your family?
Pregnancy History/ Mother
While pregnant with this child was the mother under a doctor’s care?
During pregnancy, did the mother:
Take any medications?
Drug Use?
During the pregnancy were there any complications?
Mother’s health during pregnancy:
Drink alcohol?
Smoke?
Mother’s health during pregnancy:
DEVELOPMENTAL HISTORY
As well as you can remember, where there any delays in the follow areas?
MEDICAL HISTORY
Hospitalization
Medications
History Substance Use
(please indicate if currently using)
Vaping
Marijuana
Other Drugs
Alcohol
Tobacco
Prescription Pills
History of Abuse
Emotional
Physical
Sexual
History of Trauma
Close Death
Natural Disaster
Divorce
Move
Accident
Crime
Suicidal / Self Harm
Suicidal Thoughts
 

 
 
Suicide Attempt 
Current
Current
Self Harm
 
Current
Past
Past
Past
Spiritual
Goals:

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